In recent years, the body of literature that deals with trying different ways of integrating spirituality into psychotherapeutic practice has grown exponentially. Probably the interest in this topic has arisen with regard to the inclusion in the DSM-IV of the new category "Religious or Spiritual Problem" (Code V62.89). Until then, religious or spiritual issues had been viewed in the clinical practice as symptoms of some mental illnesses like, for example, the delusions with religious content typical of schizophrenics. But with the fourth edition of the aforementioned manual, there began to be an interest in the study of spirituality as it expresses a fundamental aspect of personality. In this vein, various models of integration of spirituality and psychotherapy have been formulated. Our intention is to study the problem of incommensurability as one of the epistemological and methodological problems that supposes a project of this type. We present the writings of the Desert Fathers as an explanatory model that guarantees an epistemologically legitimate integration of spiritual traditions with psychotherapeutic practice. And for that reason, we argue that their writings could constitute a way to overcome the relationship of mutual incommensurability that apparently exists between scientific rationality and spirituality.
En los últimos años ha crecido exponencialmente el cuerpo de literatura que se ocupa de ensayar diversas maneras de integrar la espiritualidad en la práctica psicoterapéutica. Probablemente el interés por esta temática haya surgido a propósito de la inclusión en el DSM-IV de la nueva categoría «Problema religioso o espiritual» (código V62.89). Hasta entonces las cuestiones religiosas o espirituales habían sido objeto de la clínica en tanto síntomas de algunas enfermedades mentales, como los delirios con contenidos religiosos propios de los esquizofrénicos. Pero con la cuarta edición del citado manual comienza a interesar el estudio de la espiritualidad en tanto que expresa un aspecto fundamental de la personalidad. En esta línea, se han formulado diversos modelos de integración de la espiritualidad y la psicoterapia. Nuestra intención es estudiar el problema de la inconmensurabilidad como uno de los problemas epistemológicos y metodológicos medulares que supone un proyecto de este tipo. Presentamos los escritos de los Padres del desierto como un modelo explicativo que garantiza una integración epistemológicamente legítima de las tradiciones espirituales con la práctica psicoterapéutica. Y por eso mismo argumentamos que sus escritos podrían constituir una vía superadora de la relación de mutua inconmensurabilidad que aparentemente existe entre la racionalidad científica y la espiritualidad.
In recent years, the body of literature that deals with trying different ways of integrating spirituality with psychotherapeutic practice has grown exponentially. Interest in this topic has probably been reignited due to the inclusion in the DSM-IV (1994) of the category "Religious or Spiritual Problem". The aim of this new category (V62.89 [Z71.7]) is to include and deal with psychological difficulties or mental disorders that may involve loss or questioning of faith, problems associated with conversion to new faith or questioning of spiritual values.1 The DSM-IV classifies it as a problem that may be of clinical interest due to causing psychosocial pain or suffering, but it does not categorise it as a disorder per se.
Before this category was developed, religious beliefs, practices and experiences were considered neuroses by mental health professionals. In other words, they were only considered by clinicians as symptoms of some mental conditions, such as delusions with religious content that are suffered by people with schizophrenia.
After incorporating this category, people began to show an interest in studying spirituality as it is a fundamental aspect of personality and personal identity; spirituality is understood to be the core beliefs and values lived by the patient.
Concomitantly, some critical studies have been published regarding the lack of training for psychotherapists to enable them to diagnose and empathise with the patient in this type of problem.2–8 These studies and statistics show, in one way or another, how therapists address issues regarding the patient's spirituality with little or no professionalism.
In response to these critical studies, there has been a significant increase to date in the number of publications testing diverse models integrating spirituality and psychotherapy.9–15 However, the interest in integrating spirituality into psychotherapy is shown not only by the growing amount of literature on the subject but also by the establishment of several organisations devoted to developing integrative models of spirituality and psychotherapy.1
In one way or another, the literature and the aforementioned organisations present spirituality as an important domain, not only for diagnostic assessment but also for therapy purposes. They highlight that what is recognised in clinical practice as "spirituality" unleashes or paralyses psychological dynamics that are relevant for personality development. A particular type of spirituality may cause depression, mania, masochism, hysteria, phobias or obsessive behaviour. Or, in contrast, it may also cause some religious values or practices to become healthy psychological habits or structures. In this sense, religion and spiritual life may act as protective and promoting factors for mental health, especially with regard to disorders such as depression, anxiety and substance abuse.
Therefore, spirituality itself is a point of interest for mental health sciences. As a result, it is also important that psychiatry or psychology be properly associated with the religious and spiritual world. In other words, if the psychological structure or dynamics has a spiritual component, it would be epistemologically illegitimate reductionism for mental health professionals not to address the patient's spiritual dimension.
Based on this dialogue between mental health sciences and the infinite modalities of spirituality, various integration models have been tested to date. The term "integration" refers to the different projects aimed at achieving a mutual understanding of spiritual and psychological perspectives.16
There can be no doubt that the historical relationship between psychotherapy and spirituality has been mutating through various positions that could be characterised (at the risk of oversimplifying) as separation, conflict and complementarity models. The complementarity paradigm seems to be gaining more and more strength at present. This point of view is consistent with the idea that psychology and spirituality have a lot to offer each other and therefore interaction between the two should be encouraged.17–20 While there is a wide range of approaches within the integration movement, there is broad consensus among its members that psychology and spirituality have the potential to enlighten one another.21
To follow on from this last line of research, our intention is to present the idea that the study of some late-antique writings from the patristic era may be relevant today for psychology and psychiatry and, based on a very specific issue, namely, that there may be a relationship of mutual incommensurability between spirituality and mental health.
Recent studies on the treatment of certain psychological and spiritual dynamics by Evagrius and Cassian (conspicuous representatives of early Christian monasticism) support this larger project that seeks to establish bridges between spirituality and psychiatry. It should be noted here that, in recent decades, the work of these authors has aroused the scientific community's interest in their particular approach to different psychological and spiritual disorders.22–33
The fruitfulness of the dialogue with these late-antique thinkers is presented in order to rethink the criteria adopted both in research and in clinical practice to address the patient's psychospiritual dimension. First, based on a text by John Cassian, a disciple of Evagrius, we will analyse the relationship of mutual incommensurability that may be established between spiritual and clinical criteria. This not only illustrates the problem but also offers a possible way to overcome it. Second, the characteristics of the treatment that these patristic authors ascribe to certain afflictions of the soul are described. This particular approach is what could constitute, in our opinion, a possible explanatory model capable of guaranteeing an epistemological integration that overcomes the aforementioned relationship of mutual incommensurability.
Psychotherapy and spirituality: a relationship of mutual incommensurabilityBefore discussing the issue at hand, it is necessary to make a brief conceptual digression about the variable that is being analysed under the concept of spirituality. For this purpose, we followed the study by Vachon et al.,34 who, by conducting an exhaustive search of empirical studies in the MEDLINE and PsychINFO databases from 1996 to 2007, found 11 different dimensions or elements collectively referred to as spirituality: meaning and purpose in life; self-transcendence that allows one to be in harmony and at peace with oneself; transcendence with a higher being; feelings of communion with one self, with God, with the universe or nature within a network of interpersonal relationships; a body of beliefs that are the object of faith; hope understood to be an attitude towards the difficulties of life; attitude towards death; appreciation of life; personal values; a dynamic process; and its conscious aspect.
In view of this wide range of dimensions relating to the notion of spirituality in the existing literature, in our study we have focused only on variables 5, 10 and 11. In other words, we understand spirituality to be a dynamic and conscious process in which a system of beliefs is experienced. This definition does not claim to be a comprehensive definition capable of covering all the elements analysed by Vachon et al. but it is sufficient to avoid the ambiguity of this concept that has repeatedly arisen.35–39
The distinction between spirituality and religion is broadly agreed upon.40,41 While religion is defined as a system of organised beliefs, rituals and cults with a view to establishing a relationship with a divine being,42 spirituality, as we have just pointed out, is understood to be a more inclusive reality than religion.43
Our study focuses on the subjective, dynamic and conscious practising of a specific religion, Christianity. In this regard, when studying Christian spirituality using the variables mentioned above, it could be said that both spirituality and religion are identified, although without ignoring the broader scope of the notion of spirituality. Practising Christianity as a religion does not exhaust the various forms of spirituality but in itself constitutes a complete modality of spirituality.
The next section looks at contradictions that may arise as a result of an exacerbated distinction between spirituality and religion.
One of the main obstacles encountered by psychotherapists when dealing with spirituality is the relationship of mutual incommensurability that may exist between their psychopathological reading of certain spiritual experiences and the meaning attributed to them by religious traditions. One set of symptoms may be interpreted in a reciprocally incommensurable way by psychiatry and religious authors. From a phenomenological point of view, that is, in the presence of the same symptoms, a psychiatrist may find enough evidence to diagnose a bipolar or obsessive-compulsive disorder or a recurrent depression. On the other hand, a desert father may recognise the signs of a divine purification.
To some extent, this difficulty has already been studied by Andrew Powell (founding chair of the Royal College of Psychiatrists in the United Kingdom) through 2 case studies that he analyses in Chapters 3 and 5 of Spirituality and Psychiatry. In these chapters, he points out the possibility that a single phenomenon, such as guilt or the redemptive sense of pain, can be interpreted in a reciprocally incommensurable way by theologians and psychiatrists. He relates the anecdote of a colleague of his, whose patient confessed to him that the Holy Spirit had helped her bear the cross of her illness. This made his colleague so uneasy that at their next session he asked her if she was seeing ghosts. In our opinion, this anecdote perfectly illustrates the tension that can exist between theological and psychiatric perspectives in the presence of certain symptoms. It illustrates the circumstances that place psychotherapeutic practice before its own hermeneutic limits and the need to develop new resources to face the patient's spiritual dimension.
Nevertheless, with the intention of being didactic and self-consistent, this relationship of mutual incommensurability is illustrated below in a brief text from The Conferences by John Cassian (360–435).
Psychotherapists can certainly not identify a specific disorder by looking only at the symptoms revealed in the abbreviated text. It is only when they look at the course of the symptoms and are able to give a prognosis regarding treatment that they find themselves in a position to be able to recognise a specific nosological entity. This condition makes it possible to delimit the scope and limits of this methodological resource.
Analysing this text makes it possible to formulate a mental experiment. This is a hypothetical scenario that has no other purpose than to highlight the limitations and obstacles presented by an explanatory model that reduces, explains or becomes a spiritual experience in psychopathological terms.
This paper is nothing more than a methodological resource that allows us, on the one hand, to analyse in detail (however hypothetically) the problem of incommensurability. On the other hand, it allows us to study the type of approach that the fathers adopt towards spiritual and psychological sufferings, a question that is dealt with in the second section of our paper.
Cassian has the merit of discerning the movements that the soul suffers in its search for God to a greater extent and with greater clarity than the rest of the fathers. He describes in detail the process through which the soul experiences divine incognoscibility and is purified from false images or representations of God. Before him, Clement of Alexandria (150–215) and Origen (185–253), based on the image of the Exodus of the people of Israel and their crossing of the desert guided by the dark Cloud, refer to the vicissitudes and sufferings that man has to go through in his pilgrimage towards God. In chapter 2, entitled "Of the sudden changes that the soul experiences," he writes:
"Why is it that sometimes, finding ourselves in our cells, we feel our hearts filled with immense joy, and, amid this ineffable joy, we feel like we are invaded by a barrage of spiritual feelings and lights? This is such a phenomenon that it cannot be translated into words. Even the mind feels incapable of conceiving it. In these circumstances, our prayer is pure and extremely easy. The soul, filled with the spiritual fruits, knows this feeling as instinctively part of our moments of prayer, prolonged at times even during our sleep, and elevates us with great ease and efficiency to experience the presence of God.
But it also can be the case that, suddenly, and without any cause for which we are at least aware, we feel prey to the deepest sorrow. It is a sadness that overwhelms us and whose motive we try in vain to search and find the cause. The source of these mystical experiences is suddenly questioned. Even the cell we inhabit becomes little less than unbearable. Reading causes disgust in us, and our prayer goes wandering and errant; it becomes faulty and decayed as if we were victims of drunkenness. Then here comes the wails and inner anguish. The mind at this point is devoid of all spiritual fruit, and such is its infertility, that neither our desire of heaven nor the fear of hell is enough to awaken it from this mortal dream and shake it from its lethargy".44
If Cassian's text is analysed with the clinical eye required by psychotherapy, it is easy to notice a clear alternation between phases of suffering and constriction and others of expansiveness and joy, so characteristic of bipolar disorder.
The depressive phase is expressed in the aforementioned text as deep sorrow, a sadness that overwhelms. It is a sadness that causes what psychiatry recognises as anhedonia, a term introduced to psychopathology by Ribot45 in the middle of the last century to refer to the depressed person's inability to experience pleasure. This symptom, recognised by several psychiatrists46–51 as a core feature of endogenous depression, seems to be referred to in Cassian's text when he writes that "Even the cell we inhabit becomes little less than unbearable. Reading causes disgust in us". In this state, the monk not only does not enjoy or get pleasure from anything around him, but is also incapable of feeling affection in general. He lives in a kind of lethargy that the Cenobite monk expresses clearly in the way he leads his prayer: "Prayer goes wandering and errant; it becomes faulty and decayed as if we were victims of drunkenness".
Another core symptom of the depressive phase is the psychomotor inhibition52,53 expressed in the text: "The mind at this point is devoid of all spiritual fruit, and such is its infertility, that neither our desire of heaven nor the fear of hell is enough to awaken it from this mortal dream and shake it from its lethargy". The monk is paralysed, immersed in a kind of sleep from which he cannot awaken. There is inhibition of the psychological functions, manifested by his inability to pray.
On the other hand, the manic phase manifests itself in that "ineffable joy", mental agility, ease and efficiency with which the monk seems to remain in the presence of God.
The religious author also refers to the total absence of conscious causes that can be mentioned as triggers of these movements of contrition or joy. For the author, they have no natural cause. They are not the result of the psychological dispositions that give rise to the different forms of asceticism that the monk practices, such as fasting, vigils, solitariness or silence. These are movements that should be attributed exclusively, according to Cassian, to the mercy of God: "All this offers us a certainty that it is divine grace and mercy that operates in us for all good, and that without Divine help our diligence is useless. The word of Scripture is fulfilled incessantly in us: "It is not the work of the one who desires, nor of the one who runs the race, but of the mercy of God".54 Psychiatry, on the other hand, can recognise in such passivity the sudden and unmotivated onset of the phases of affective alternation experienced by the manic depressive as states totally beyond his control.
It is important to note here the mutually incommensurable interpretations that can be formulated respectively by psychiatry and patristic spirituality. Two theories, cultures, traditions or, in this case, diagnoses that are incomparable or imperfectly translatable, due to lacking a common metre or pattern, are said to be incommensurable. Therefore, there would be no rational criteria to discern whether one is better or truer than the other.
Thus, in the case at hand, we do not have the necessary criteria to determine on the basis of patristic spirituality whether what is referred to here as divine consolations are nothing more than what psychopathology refers to as manic phases. And vice versa. There is no criterion to determine whether, when psychopathology speaks of a depressive phase, is it referring to the purification phenomenon described by the religious author. In short, the necessary conceptual tools do not seem to be available to be able to discern whether the two definitions offer alternative descriptions of a common domain of entities or not. In this case, there would be a long-standing relationship of mutual disagreement between Christian spirituality and the mental health sciences in that they would be informed by mutually exclusive ontologies. They read, select, diagnose, explain and treat symptoms according to their particular way of understanding the health of the soul. By virtue of this, there is no method and no empirical evidence to resolve such questions. Each of them has its own means of coding and interpreting evidence. There are no universal empirical criteria to answer these questions. And, in this sense, there would be no experimentation model that could be used (as a common and neutral basis) to corroborate one explanation of the spiritual experience and falsify another.
It is not at all our intention to deny the possibility of mixed cases, where the mystic displays the symptomatology - so to speak - characteristic of the dark night, and simultaneously suffers from pathological tendencies.55 A spiritual dynamic can accidentally feed and provoke pathological conditions. Furthermore, pathological tendencies can acquire greater vitality and become more tyrannical under a particular spiritual process. A spiritual experience can certainly coexist with a psychological disorder. But a very different situation —and this is the one that concerns us here— is that spiritual experience is categorised as pathological due to the epistemological limitations of psychopathological models.
As such, it is appropriate here to revisit the question: do the mental health sciences have the necessary tools to address what is recognised as a religious or spiritual problem? From the practice of these same sciences, is it possible to distinguish a strictly psychological condition from that dynamic that is concomitant and typical of spiritual crises?
In view of this incommensurability, the following dilemma emerges: either the mental health sciences must admit the failure of their own principles to account for subjective spiritual experiences, or it must be assumed that both scientific explanations and those offered by spiritual traditions are no more than arbitrary descriptions, all of which are equally valid or equivalent.
This dilemma leads us to the next point: which elements should the mental health sciences incorporate to guarantee an epistemological integration with spirituality and thus overcome the aforementioned relationship of mutual incommensurability? In our opinion, the writings of the Desert Fathers offer us a possible hermeneutic and integrative path.
The integrative model of the desert fathersHow the monastic authors of the first Christian centuries approach psychospiritual phenomena constitutes a paradigmatic model of how to deal with the continuity between psychology and spirituality. It is a continuity that, due to the various epistemological prohibitions of modernity, the current mental health sciences are unable to explain. There is no doubt that such a theoretical integration is a long and difficult path, however it is the only way to avoid repeating the dead end that the problem of incommensurability leads to (in addition, there is probably another important problem: i.e. that there are so many and so diverse theoretical perspectives defended by the various therapeutic schools that it becomes too dense and complicated to try to include them all). Thus, an effective way forward may be to analyse avenues of theoretical integration between, for example, the fathers' spirituality and a particular psychological school.
The following should be considered here: Based on what criteria could the Desert Fathers formulate an integrative model between spirituality and contemporary psychotherapy? What would be the guiding principles to achieve a functionally articulated and significantly integrated unit? Is it possible to build a whole between such apparently different parts? What would be the focal point, the point of confluence of what in modern language is recognised as 2 subsystems or paradigms? And further radicalising the approach, one could object: even admitting the possible contribution of the Desert Fathers to the genesis and development of treatments for the ailments of the soul, can their writings facilitate integration criteria for a science that in its contemporary developments is absolutely unrelated to them? What could be the contribution of studying instances already surpassed by the progress of contemporary psychiatry or psychology?
What this type of question and approach actually does is install a reciprocal incomprehension between psychotherapeutic practices and spiritual traditions, in this case represented in patristics. It enquires about common criteria —be it at an observational, linguistic or methodological level— in which relations of mutual incommensurability are naturally revealed. In our opinion, the issue needs to be approached in different ways. For this purpose, it is necessary to first understand the limits and scope of the problem of incommensurability, as defined by Paul Karl Feyerabend.
If we take into consideration the purpose for which Feyerabend originally formulated the doctrine of incommensurability, we understand that it was to introduce it as a pseudo-problem, a reduction to absurdity of a particular way of understanding scientific rationality, that is, of the attempts of critical rationalism and logical positivism to define science in terms of an empirical or methodological foundation: "There is no attempt on my part to show 'that an extreme form of relativism is valid.' […] I do not try to justify 'the autonomy of every mood, every caprice, and every individual'. […] I merely argue that the path to relativism has not yet been closed by reason so that the rationalist cannot object to anyone entering it".56
Incommensurability proves the impotence of these particular models of rationality to justify scientific objectivity. With the principle of consistency, the epistemologist explains, experimentation or observational statements are the neutral and objective foundation that allows one to corroborate or falsify a theory. The substitution of ontology, tradition or culture presented by certain theoretical transitions invalidates precisely this possibility of falsifying or intersubjectively determining the verisimilitude of theories. Therefore, if the empirical evidence or observational statements do not have the same sense or meaning in the competing theories, they cannot constitute the common basis for corroborating one theory and falsifying another.57
However, the Vienna-born scientist in no way sought to deny the possibility that two theories, cultures, practices or traditions can reach a reciprocal understanding through a process of immersion or familiarisation in the language and in the world of meaning that the other theory implies.58,59 This path of mutual understanding had to be traced, of course, through a practice different from that traced by positivism and critical rationalism.60,61
Feyerabend formulates what he calls the historical-anthropological method of inquiry, which is nothing more than a process of immersion in the different forms of explanation or representation of an object based on dialogue and interaction with other cultures. In Farewell to Reason, he particularly points to the religious views of the world and to ancient Greek science as possible ways to judge the achievements of our science in perspective.62
Returning to the topic at hand, we believe that this immersion process in the fathers' writings can mean not only the possibility of experiencing past cultural forms, but above all, an opportunity to reformulate a central discussion that currently affects the contemporary sciences of mental health.
But it is worth noting that this anthropological study does not clarify the concepts or dynamics described in their writings according to our canons of scientific perfection, but through hermeneutics that requires attention to the particular cosmology that permeates them. Studying the works of the fathers by immersion means analysing them from their own values or principles, and not according to whether they fit in with or deviate from formal or abstract models of our modalities of rationality.63
In this sense, we are far from understanding the fathers as promoters of a new method, a typically modern project that is completely foreign to their interests. What we intend to show is that their writings can unveil an understanding of psychotherapeutic practice where psychological and spiritual dynamics find explanatory complementarity. Their works propose a novel intellectual and clinical approach to spiritual practice, which could represent a valid alternative that overcomes the problem of incommensurability.
The patristic writings analyse the spiritual experience from a theological context, but this does not prevent the psychological dynamics concomitant to such experience from being intelligible. Furthermore, they understand that such theological explanations are ultimately the keystone that allows us to account for the intelligibility and continuity between psychological and spiritual processes. It is not a mere juxtaposition of senses. Their writings, based on theological interpretation, develop a semiology that makes it possible to discern and systematise the signs and evolution of a spiritual state with its concomitant cognitive-emotional dynamics.
For illustrative purposes, it is worth mentioning the treatment given by Evagrius Ponticus, Cassian's spiritual teacher, of the possible role of demons in the dynamics of evil thoughts (the eight, according to the order of the Practical Treatise, are: gluttony, lust, greed, sadness, anger, sloth, vainglory and pride). The religious author of Kephalaia Gnostika tries to typify in detail the logical-imaginative activity, which is nothing but the particular ground on which the demons would elaborate their suggestions.64 In this type of treatment, it is worth noting the explanatory continuity that would exist between the religious understanding of demonic temptations and the analysis of the internal dynamics of the faculties of the soul.65
The Pontian monk not only discerns his own demon that is affecting the soul but also registers the value structure, the cognitive-emotional correlate that could be operating as an aetiological factor of his afflictions.
The Hippocratic-Galenic conception of illness as a parà phýsin (contrary to nature) state is widely present in patristic thinking (pre-, contemporary and post-Evagrius). The extent of this medical understanding of soul afflictions requires the Pontian monk to discriminate between the processes of passionate imbalance and cognitive distortion that underlie a particular spiritual dynamic. For the Cenobite monk, the soul is spiritually ill when its faculties function or are in a state contrary to nature. In other words, its faculties deviate from their natural end and therefore function against nature, moving and drifting in directions opposite to those of their true end, acting in a disorderly, irrational, absurd, senseless and insane manner. Galen's definition of disease agrees with this: "Disease is any condition contrary to nature which impedes function" ("On the differentiae of symptoms", De symptomatum differentiis, VII.43 K; compare this with the confluent definition in "On the differentiae of diseases", De differentiis morborum, II.1 VI.836−8 K).
Based on this understanding of disease, it is possible to understand the meaning and scope of the intellectual effort, which can be seen in his writings not only to interpret theologically a spiritual experience but also to account for the underlying psychological dynamics. This explanatory model developed by the fathers is the model that, to our understanding, makes synergy and mutual intelligibility between health (understood in Hippocrates' and Galen's coordinated efforts)66,67 and certain dynamics of Christian spirituality possible. We are certainly faced with an outdated medical model, but what we are really interested in highlighting is how knowledge from that era regarding mental health and the understanding of spiritual dynamics are integrated.
This model developed by the fathers represents a possible model for contemporary psychotherapy to enrich its understanding of spiritual dynamics. It is a model that combines a theoretical and clinical approach to spiritual experiences and, in this respect, constitutes a possible path for the mutual understanding of psychotherapeutic and spiritual practices.
The fathers appeal to the mental health sciences to retrieve from religious traditions their vast knowledge of spirituality. They highlight the need for psychotherapists to have a specific understanding of how spirituality is understood in different religious traditions. This is because this theoretical background is what would allow them to understand the patient's subjective experience from their own significance.
If the mental health sciences seek to recognise an identity and autonomy to the patient's spiritual dynamics, they should undertake the task of treating the semiology inherent to all conditions described in the DSM-IV as belonging to the category "Religious or Spiritual Problem". This means the semiology of a conversion, purification, loss of faith, in order to differentiate them from affective or psychopathological disorders. And to do so by paying particular attention to the theological context in which the patient is living.
In this task of semiological discernment, the psychotherapist may come across symptoms that are certainly analogous to a psychopathological disorder, such as periods of extreme joy followed by phases of contrition. These symptoms could provide the psychiatrist with clues that would allow him or her to reasonably diagnose (at least from the current models of psychopathology) a bipolar disorder. However, it must be stressed that this diagnosis could be the result not of a proper clinical opinion about the patient's situation, but of the same limitations of the diagnostic models, which ignore the dynamics, the strong emotional responses that can trigger the value structures of a particular spiritual experience within the framework of a particular religious tradition.
In this case, the therapist must consciously record the semantics, the world of meaning, that may be sensitively provoking the patient's behaviour and emotional response. A dark night - to continue with the case analysed in the previous point - brings all its miseries to the sufferer. It is a kind of painful awareness of his nothingness and the emptiness of his false representations of divine love. This naturally triggers a period of sadness, which later turns into joy. After all, the patient does not have two different ways of reacting sensitively to what he or she values as good or bad based on their spiritual experience.
The purpose of psychotherapy is unquestionably the subjective experience and not the institutional and doctrinal aspects of religion. However, paradoxically, only by appealing to the theoretical and semantic principles of a religious tradition will the professional be able to access the evaluative, emotional and cognitive structures of the patient's experiences of transcendence. After all, spiritual experiences do not occur in a vacuum. There are semantics that permeate them, an internal rationality from which the therapist must interpret and make understandable the patient's individual experience.
William James, in stressing the division between religion and spirituality, would seem to continue a long tradition of empirical research that reduced spirituality to perceptions or extraordinary states of consciousness.68–74 The American philosopher effectively changed the view of the mental health sciences of the spiritual world and initiated a research tradition that abandons the project of interpreting spiritual experience from psychopathology.75 Nevertheless, his paradigm shift or change is still indebted to the strictly empirical approach of his predecessors. It reduces spirituality to a particular state of consciousness. It seems that this phenomenal basis would be the common denominator of all the modalities or forms of spirituality, which would, according to this epistemological tradition, allow us to study spirituality rationally and scientifically.
In this sense, while spirituality, in its multiple dimensions, constitutes an object of scientific rationality, religion, understood to be a semantic body of beliefs and particular practices, would naturally belong to a pseudo-scientific instance.
Exacerbation of this division between spirituality and religion, or the relationships of mutual incommensurability that empirical tradition establishes between the two, leaves the clinician and psychotherapeutic task with a dark and empty concept.
Exacerbation of this distinction leaves the psychotherapist without a semantic framework, without criteria to judge the patient's subjective experience. Spirituality becomes a collection of unusual experiences; a mere alteration of consciousness. This understanding clearly indicates an underestimation of the richness and density of the infinite forms and modalities in which spiritual life has been portrayed by the many religious traditions. But how can the cognitive and emotional structures of a particular spiritual experience be disclosed without understanding the semantic framework that the patient assigns to that experience? In one way or another, incommensurability puts in check this separation between religion and spirituality, between science and pseudo-science. It shows that certain types of empirical study, by not considering the various religious traditions in their experimental designs, are unable to account for the spiritual problem or condition of their patients.
Of particular note is the effort in recent years to formulate spiritual assessment tools, such as the Rush Protocol, to screen for religious or spiritual struggle,76 Steinhauser's single-item assessment tool that is based on the question "Are you at peace?",77,78 Mako's screening tool, which primarily asks whether the patient has spiritual pain,79 or the Spiritual Injury Scale.80 While these tools certainly mean progress in the task of standardising spiritual problem assessments, they tend to broaden the gap between religious significance and spiritual problem screening methods. These are tools that do not provide any data regarding the content and evolution of a spiritual problem, as pointed out by Balboni et al.81
It is certainly necessary to standardise tools that assess problems of a spiritual nature in order to improve the diagnostic capacity and efficacy of interventions. But this cannot be done at the expense of losing knowledge provided by religious traditions in such measurements, which ultimately can account for many variables that may intervene in the cognitive-emotional structures that affect the emotional, psychological and spiritual well-being of the patient.
Studying the writings of the early Christian monastic fathers challenges us to critically review our models of approach to what is recognised as a "religious or spiritual problem". In particular, modalities or approaches that transcend relationships of mutual incommensurability between psychotherapy and spirituality could be used in their treatments.
The Desert Fathers highlight the need for the mental health sciences to access knowledge of religious traditions in order to account for the psychological dynamics underlying a spiritual practice. By immersing themselves in the semantics of Christian spirituality, they make possible the sensitive and intellectual intelligibility of the symptoms of a particular spiritual experience. However, this immersion of psychotherapy practice into religious traditions obviously has a bearing on the problem of incommensurability: by understanding the synergy that exists between psychological dynamics and the semantic structures that trigger them, the problem of incommensurability as such cannot be formulated.
This is a strange paradox: as elements and principles apparently unrelated to scientific rationality are incorporated, scientific demonstrations acquire explanatory power. In other words, as psychotherapy addresses the conceptual framework of religious traditions, it is able to account for religious experience. This process of immersing or making psychology and psychiatry familiar with the universe of religious traditions excludes in itself the problem of incommensurability. In contrast, if they are lacking such knowledge, they are not only blind and insufficient to understand the dynamics of spiritual experience but also open up what we describe as a relationship of mutual incommensurability between spirituality and mental health.
Evidently, the problem of incommensurability arises in a completely different context from that of the patristic writings. Therefore, directing this problem at the Desert Fathers would seem not only anachronistic but also illegitimate, since they do not sustain the assumptions that lead to it. Our intention here has not been to bring to your attention a problem that you have not dealt with, but to present the characteristic notes of your understanding of spiritual experience that particularly prevent the absurdity of incommensurability from arising. And, in this regard, to understand some of the virtualities of your particular approach to the afflictions of the soul.
ConclusionsPsychotherapeutic practice and psychopathology itself should be conceived as a hermeneutic activity in its dealing with the other, rather than as an epistemological model of the psychological domain. If psychopathology follows the latter path, it tends to obliterate the fundamental area of meaning that is religiosity and becomes, paradoxically, an attitude that contributes to the patient's loss of freedom and mental health.
Incommensurability shows the absurd or obscure situations that arise in psychotherapeutic practice to the extent that psychopathology is conceived as a rigid epistemological model capable of distinguishing itself from apparently metaphysical, irrational or pseudo-scientific domains. In a positive sense, it can be said that incommensurability, as defined by Paul Feyerabend, is an attempt to show the need to search for a broader, all-encompassing conception of scientific rationality capable of addressing metaphysical theses.
In view of the above, it could be concluded that, in order to overcome the mutual incommensurability between the mental health sciences and spirituality, the former must recognise religion as a central explanatory element of the cultural context and of the patient's own personality. Psychotherapeutic practice should pay attention to the implications of religious dogma, rituals and practices on the cognitive, emotional, affective and behavioural patterns of patients. Jung was able to point out that religions "are psychotherapeutic systems in the truest sense of the word, and on the grandest scale".82 In one way or another, this gives relativity to the historical distinction between spirituality and religion, for after all, without religion, spirituality is unintelligible. The doctrinal or theoretical elements of religion account, at least partially, for the psychological dynamics underlying the patient's spiritual experiences.
The writings of the early Christian monastic fathers formulate a possible model that guarantees an overcoming integration of the aforementioned relationship of mutual incommensurability. They require us to think about spirituality from within itself, that is, before the need to discern the psychological dynamics from their respective theological frameworks.
Studying the therapeutic approaches of these profound connoisseurs of the human spirit is by no means a naive regression to the primitive and unscientific stages of psychiatry or psychology. Nor does it imply contempt for the long tradition through which modern science has been perfecting itself. On the contrary, in our opinion, their study presents the possibility of thinking about psychological structures in close connection with spirituality, which is nothing but the thesis sustained by the aforementioned current studies of psychiatry.
The dialogue and interaction with the early Christian monastic fathers are, in our opinion, an opportunity to judge in perspective the achievements of contemporary scientism and to rethink the rationality of psychotherapeutic practice as a cognitive task more attentive to the psychic and existential implications of religious traditions. They challenge modern psychiatry and psychology to accept religion as an object of the clinical reality of the patient.
FundingThe research was funded for both authors by CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas de Argentina - National Council for Scientific and Technical Research of Argentina).
